OPIOID RISK TOOL (ORT) - by Lynn R. Webster MD

Patient name:
Date:

ITEM	Female Patient	Male Patient
Q1. Family History of substance abuse:
Alcohol
Illegal Drugs
Prescription Drugs
	*******	*******
Q2. Personal History of substance abuse:
Alcohol
Illegal Drugs
Prescription Drugs
	*******	*******
Q3. Age (between 16-45 years old)
	*******	*******
Q4. Hx of preadolescent sexual abuse:
	*******	*******
Q5. Psychological Disease
ADHD, OCD, Bipolar, Schizophrenia
Depression

RISK ASSESSMENT AND SUGGESTIONS:

Score	Action
0-3	Low risk: good candidate for opiate use.
4-7	Medium risk: use opiates with caution.
8 or higher	HIGH RISK: use opiates with extreme caution. Consider treatment agreement.

Subject: